Can misoprostol (prostaglandin E1 analogue) or dinoprostone (prostaglandin E2) gel be used for medical termination of pregnancy in patients with Eisenmenger syndrome?

Prostaglandins Are Absolutely Contraindicated in Eisenmenger Syndrome

Neither misoprostol nor dinoprostone gel should be used for pregnancy termination in patients with Eisenmenger syndrome—prostaglandin-induced labor is explicitly contraindicated due to life-threatening hemodynamic fluctuations, and surgical termination via dilation and evacuation (D&E) is the only acceptable method. 1

Why Prostaglandins Are Dangerous in Eisenmenger Physiology

Hemodynamic Catastrophe Risk

• Prostaglandin F compounds (and related prostaglandins) increase pulmonary arterial pressure and decrease coronary perfusion, which is catastrophic in patients who already have severe pulmonary hypertension with right-to-left shunting 1
• Systemic vasodilation from prostaglandins increases the right-to-left shunt and decreases pulmonary flow, leading to increased cyanosis and potentially a low cardiac output state 2
• The maternal mortality in Eisenmenger syndrome is already 20-50%, occurring most often in the peri- or post-partum period, and prostaglandins would dramatically worsen this risk 2

Guideline-Based Contraindication

• The American Heart Association explicitly recommends that patients with severe cardiovascular disease such as pulmonary arterial hypertension should avoid medical termination of pregnancy due to high risk 1
• This is not a relative contraindication—it is an absolute one based on the pathophysiology 1

The Only Safe Approach: Surgical Termination

Recommended Method

• The American College of Cardiology recommends surgical termination, specifically dilation and evacuation (D&E), as the safest procedure in both first and second trimesters, with lower rates of hemorrhage and infection compared to medical methods 1
• D&E allows for controlled hemodynamics under anesthesia with continuous monitoring, unlike the unpredictable hemodynamic swings of prostaglandin-induced labor 1

Critical Perioperative Requirements

• Transfer to a tertiary center with on-site cardiac surgery capabilities before attempting termination, with a multidisciplinary team including adult congenital heart disease cardiologist, cardiac anesthesiologist, high-risk obstetrician, and cardiac surgeon on standby 1
• Optimization of hemodynamics is crucial: maintain oxygen saturation, avoid dehydration, ensure adequate preload 1
• Meticulous attention to avoiding air bubbles in all IV lines due to right-to-left shunting risk of paradoxical embolism 1
• Maintain systemic vascular resistance to prevent increased right-to-left shunting 1

Post-Procedure Critical Period

• The first several days after termination carry particularly high maternal mortality risk in Eisenmenger patients, requiring ICU-level monitoring for at least 48-72 hours post-procedure 1
• Continue pulmonary vasodilator therapy if the patient was on it pre-procedure 1
• Aggressive prevention of thromboembolism while balancing bleeding risk 1

Common Pitfalls to Avoid

Never Use Medical Termination

• Even though misoprostol is FDA-approved for abortion and dinoprostone for cervical ripening 3, 4, these approvals do not apply to patients with Eisenmenger syndrome where they are contraindicated 1
• The general warnings about uterine rupture and cardiovascular effects in the FDA labels 3, 4 are magnified exponentially in Eisenmenger physiology 1

Anesthesia Considerations

• Regional anesthesia (epidural) has been used successfully in case reports 5, but requires intensive monitoring and careful titration to avoid systemic vasodilation
• General anesthesia may be preferred for surgical termination to maintain tight hemodynamic control 6

Post-Termination Contraception

• Patients with Eisenmenger syndrome should consider permanent contraception such as tubal ligation or endoscopic sterilization, as pregnancy is absolutely contraindicated 1
• Progesterone-only methods may be considered as interim contraception 1